Billy James Jenkins · Prevention of Future Deaths report

On 17 October 2019 I commenced an investigation into the death of Billy James Jenkins, 31. The investigation concluded at the end of the inquest on 20 February 2020. The medical cause of death was asphyxia due to being suspended by the neck, with underlying alcohol and cocaine intoxication. The conclusion of the inquest was that Billy Jenkins took his own life by hanging following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

On 12 August 2019 Billy Jenkins was found hanging by the neck in a hotel room bathroom. He had checked in the early hours of the morning after visiting his mother and presenting as unusually calm. Billy Jenkins had a long history of alcohol and cocaine abuse when he was feeling in low mood. An empty bottle of vodka was found in the room. There were a number of social factors contributing to his low mood at the time of the incident. He had reported ongoing suicidal ideation, and reported three previous suicide attempts but no active plan. He had been prescribed anti-depressants by his GP.

He generally presented as agitated and impulsive but had always sought support from clinical services but had been resistant to alcohol and drug support believing that he had an undiagnosed bipolar disorder.

He was assessed by ADAPT on 3 July 2019 but left the assessment feeling hopeless. His mother was present throughout his assessments and felt that he had not been listened to, that he had not been diagnosed and that insufficient information had been gathered at assessments to be able to properly support him.

(1) The findings of the internal investigation by Oxleas NHS were that the assessment undertaken by the Community Mental Health Nurse did not illicit sufficient information to enable the multidisciplinary team to properly review Mr Jenkins’ mental health. Despite this the multi-disciplinary team proceeded with a review and decided that he did not have a mental health condition, without seeking a further assessment
(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask.
(3) As a direct consequence of the limited information gathering Billy Jenkins was not properly assessed and it was not known whether he had a mental health diagnosis which required treatment.
(4) It was not known whether as a result of this death there had been any lessons learned by the teams involved in care and treatment of Billy Jenkins, or whether there had been any training or support requirements identified for the Community Mental Health Nurse.